You Are the on Call Doctor

You are the on–call doctor.

You feel you are dealing with your share of repeat prescriptions.

It’s Monday so there are loads, as well as more visits than usual and full surgeries.

A lot of the scripts have a note on them saying ‘Medication Review Due’. In your practice, the system is for the doctor signing the prescription to decide what to do about this.

You wish you had time to devise a systematic approach.

Practice systems for repeat prescriptions and allocation of tasks in general

On-call doctor and duties

‘Medication Review Due’ messages and how to deal with them

For each of the scripts, you do one of the following:

If it looks as if everything you might have done in a medication review has been done in the last consutlation, you change the review date on the computer (and feel cross with the doctor who saw them and failed to do this) (then you notice that in some cases that doctor was you)

If it looks like they need some QOF bloods or a BP check, you leave them a note telling them to see the practice nurse

If you feel the medication doesn’t really need reviewing (e g 30 loratadine in June, for the first time since last June), you change the review date on the prescription

If you feel the patient really needs seeing, you ask them to make an appointment with a doctor. You wonder exactly what such an appointment should consist of, and how the patient feels when they are asked to make one.

You wonder if there ought to be a clearer practice policy, how it would be developed, how it would be implemented and whether it’s worth trying to do anything about it.

What is a medication review?

How are practice policies devised and implemented? What factors make such things more likely to succeed?

Role of the practice nurse?

The doctor’s and the patient’s perspectives?

A week later, the appointments screen shows that your second patient has come for a medication review.

Her name is is Ruth Denton. You haven’t met her before.

You look through the records and find the following

Her date of birth is 24.9.1948

She registered with the practice 8 years ago
She was on Femoston-conti, one tablet daily, when she registered and has stayed on it ever since
She has had a few review appointments in which her BP has been checked, and she’s said that she feels well and isn’t having any vaginal bleeding
You can’t find any information about when she started it or why

What are your aims for this consultation?

Dealing with situation when you might feel out of your depth

Unfamiliar medication
Lack of past history information
Unknown patient

You ask her a bit about herself – she works full time as a secretary in a solicitor’s office, her husband works for Yorkshire Water and has 2 children at university. She seems generally positive about life.

You ask her about the HRT:

She started it 10 years ago when she was 49 and her periods stopped; she had some hot flushes and night sweats
She was a patient in a large practice which had a ‘well woman clinic’ led by one of the practice nurses
The nurse suggested that women who don’t have contraindications to HRT should stay on it for at least 10 years for osteoporosis prevention. She was given written information which supported this view.
When she started it she felt it improved her general wellbeing as well as her menopausal symptoms, so has been very happy to stay on it

She asks you

If you think she should stop it
If so, will her menopausal symptoms come back? Will she stop feeling so well?
What about the risk of osteoporosis?

Changing guidelines

Evidence based medicine

Role of the pharmaceutical industry

Nurse led clinics

You explain about the change in guidelines about HRT and agree about how she’s going to stop it.

You discuss the risk factors for osteoporosis (she doesn’t have them) and lifestyle measures to reduce future risk.

Current guidelines for HRT

How to stop HRT

Risk factors for osteoporosis

Your last patient of the morning is Clare Ashworth, 51.

She tells you the following

Her last period was about 8 months ago and before that they were few and far between
She wakes about 6 times a night with drenching sweats which make her throw her half of the duvet off, disturbing her husband; she drifts back to sleep and wakes again feeling very cold, pulls the duvet back over herself etc
She feels tired during the day, and is often irritable, tending to over-react emotionally
She has a lot of responsibility at work where she is a deputy head teacher of a large comprehensive school. At home, her children are working for A levels and GCSEs respectively. Her husband, an NHS manager, is under stress because of constant reorganisations at work. Her parents live nearby but her father is on the waiting list for a hip replacement and her mother seems to be getting confused and forgetful.
She has delayed coming to you because she knows that HRT is no longer recommended like it used to be, and asks you about alternatives, although she wouldn’t be completely against HRT if you really think she should have it.

What do you do in this consultation (apart from feeling relieved that she is the last patient of the session)?

How to manage a consultation which seems to have very many angles
You explain that there are physical, psychological and social elements to the situation and you will look at all of them.

You explain that although HRT is no longer recommended for osteoporosis prevention, it is still recommended for menopausal symptoms for 2-3 years

Physical

You explain that the sweats and flushes are definitely due to the menopause and explain that they are likely to last for 2-3 years, though it may be less or more
Thinking that you may be going to put her on HRT, you check her BP (it’s 128/79) and ask about FH of breast cancer (she doesn’t have one)

Psychological

You ask if she’s ever had any psychological upset before (she hasn’t)

You explore the possibility of depression (you think she probably isn’t)
You explain that irritability and ‘emotional incontinence’ are common in the menopause, but in her case they may be due to lack of sleep or to stress

Social

You tell her of the concept of the ‘sandwich woman’ – middle aged woman in the middle of a sandwich with elderly parents becoming dependent on one side, and still-dependent adolescent children on the other – plus, quite often, partner with midlife crisis on the side.
You check whether her parents are getting any help and offer her written info or carers’ support telephone number
You ask her what she does for herself – hobbies, friendships etc – and remind her that getting rest and relaxation for herself will benefit the people she feels responsble for

You offer her written info about the menopause, HRT and alternatives, and agree to see her the following week.

The menopause

Current guidelines for HRT

Monitoring HRT

Alternatives to HRT

Sources of help for carers
Remembering what you told Clare about rest and relaxation for herself, you have a cup of coffee and a short stroll in the sunshine before starting on today’s pile of repeat prescriptions.

You’ve been allocated one visit – to a Nursing Home for (guess what?) a medication review.

Marjorie Kitching, aged 93, has recently come to live at the Nursing Home and you have minimal information about her. She is on

Citalopram 10 mgs daily
Lansoprazole 30 mgs daily
Ferrous sulphate 200mgs bd
Senna 7.5 mgs at night

The old records are, miraculously, available but not very informative.

She seems to have been on the citalopram for 4 years; there doesn’t seem to have been a clear diagnosis of depression.
There’s a hospital letter from 4 years ago, explaining that the iron and lansoprazole were started together for unexplained anaemia. She had been investigated for non-specific decline and the only abnormality found was a Hb of 10.2. Ferritin and serum iron/TIBC were unhelpful. Endoscopy wasn’t thought to be justifiable.
Hb measurements since then have been 11.5, 10.6 and 11.0

She is charming but quite disorientated and with obvious short-term memory deficit. Her mobility is good with a stick and/or a person supporting her.

The nurse in charge asks you if she should be on osteoporosis prevention, but mentions that Marjorie’s daughter has asked if she needs to be on all the medication she’s come in on.

How do you proceed?

Diagnosis of iron deficiency

Antidepressants in the elderly

Medicines management in nursing homes

Balancing everyone’s point of view (especially when the patient can’t remember anything)